Bariatric to metabolic surgery: management options and experience at a tertiary centre

Obesity proves to be a growing pandemic with severe health and economic implications. Bariatric surgeries are now recognised as metabolic surgeries given the excellent resolution of metabolic derangements accompanying obesity. This concept of metabolic surgery is now applied to non-obese population with metabolic disorders. The type II diabetes mellitus remission rates as high as 95% have been reported, least with restrictive procedures and maximum with malabsorptive procedures and such effect occurs even before substantial weight loss. This has led to increased understanding of diabetes pathophysiology and formulation of foregut and hindgut hypothesis. The aim of this study was to briefly review the management options for morbid obesity and present the results at a high volume centre. Data from 518 patients who underwent laparoscopic bariatric surgeries at this institute since 2002 were taken up for analysis retrospectively. Study population included 518 patients with 310 males and 208 females. Excess body weight loss and comorbidity resolution rates were analysed. Laparoscopic bariatric surgery is safe and effective for excess body weight loss and confers excellent resolution of associated comorbidities.     

Observations of hepatic encephalopathy profile in a tertiary care centre

A study was conducted among 67 patients presenting with hepatic encephalopathy to establish the aetiological diagnosis and record the incidence of acute and chronic liver diseases. They all had undergone thorough clinical and laboratory evaluation. The factor precipitating encephalopathy was also identified. Among 67 patients 19 (28.4%) had acute liver disease and 48 (71.6%) had chronic liver disease. Majority of patients had grade 2 encephalopathy at presentation. Among the acute cases most common aetiology was acute viral hepatitis due to hepatitis B and E viruses whereas alcoholic liver disease was the most frequent cause of chronic liver disease. The most common precipitating factor was gastro-intestinal haemorrhage.     

A retrospective audit of 200 cases of CNS tumours and their surgical management in a tertiary care centre

Aims

To study the nature of the tumours managed in the Irish population.

Methods

This audit research was completed via a retrospective medical review on 200 patients with CNS tumours managed in a tertiary care centre between 2008 and 2009.

Results

The mean age was 53 years. The male:female ratio was 2:1. The majority were glioblastomas and astrocytomas. Grade IV tumours were predominant (65.5 %). Headaches (37 %), motor weakness (32 %) and seizures (25.5 %) were the highest presentations. The commonest sites affected were the left parietal and left temporal lobes. There were 17.5 % operative morbidities with motor weakness (22.9 %), seizure (14.3 %) and thrombo-embolism (14.3 %) dominating and significant association to surgical radicality (p = 0.041). 3.5 % operative mortalities were reported. 52.5 and 62.5 % of patients received adjuvant chemotherapy and radiotherapy, respectively.

Conclusions

Patients with CNS tumours typically had multiple presentations. More extensive surgical resection was associated with higher postoperative morbidities (p = 0.041). The 30-day postoperative morbidity (17.5 %) and mortality (3.5 %) were concordant with the currently available literature.     

Inpatient management of diabetes: survey in a tertiary care centre

Aims: Good glycaemic control in hospitalised patients with diabetes mellitus improves wellbeing and aids recovery. This survey aimed to: (1) assess glycaemic control in patients with diabetes admitted to hospital for reasons other than diabetes, (2) compare the glycaemic control in patients treated in medical and surgical units, and (3) see the impact of specialists'' input on glycaemic control. Methods: The first 150 patients admitted to hospital were identified; those with acute metabolic complications of diabetes mellitus, acute myocardial infarction, pregestational or gestational diabetes, and patients in different intensive care units were excluded. Case notes were reviewed with particular attention to glycaemic control, frequency of blood monitoring, complications, and the actions taken to improve glycaemic control. Results: Four of the 150 patients died in hospital. When subcutaneous insulin was used glycaemic control was good in 48%, suboptimal in 15%, and poor in 37% of patients. The results were not significantly different with subcutaneous or intravenous insulin. There was also no difference in glycaemic control among medical and surgical patients. Patients managed by designated specialists had better control than those managed by physicians (p<0.001). Hypoglycaemia was documented in 20% and two patients developed non-ketotic hyperosmolar coma while in hospital. In a few cases treatment at discharge was not changed despite poor control while in hospital. Conclusion: More attention should be given to improving glycaemic control in patients hospitalised for reasons other than diabetes. Particular care should be taken to modify the dose of insulin needed to get good glycaemic control; control was better with specialists'' input. A follow up survey will be conducted.     

Bronchoscopy in adults at a tertiary care centre: indications and complications

Fibreoptic bronchoscopy (FOB) helps in visualisation of the endobronchial tree. Fibreoptic bronchoscopies were done in 429 cases between January 1999 and January 2000 [322 men (75.1%) and 107 women (24.9%)]. Patients were between 12 and 89 years of age (mean+/- SD = 49 +/- 15.1 years). Of which, 196 (45.7%) had lung cancer and 233 (54.4%) had non-malignant disease [Tuberculosis (TB) 26, miliary TB 16, non-resolving pneumonia 29, atypical pneumonia 10, bronchiectasis 11, aspergillosis 12, sarcoidosis 17, interstitial lung disease (ILD) 20, haemoptysis with normal chest x-ray 13 and miscellaneous 79]. In this series of 429 patients a significant number of patients (n = 127) presented with fever (38 malignant and 89 non-malignant disease, p < 0.0001), 137 had haemoptysis (74 malignant and 63 non-malignant disease, p < 0.01), 89 had chest pain (61 malignant and 28 non-malignant disease, p < 0.0001) and 29 patients presented with complaint of anorexia (21 malignant and 8 non-malignant disease, p < 0.003). High prevalence of lung lesions in the right upper lobe [10.4% (43 of 411)] and left main bronchus [12% (49 of 411)] was observed. Left upper lobe showed 8.7% (36 patients) lesions and right middle lobe showed 5.5% (23 patients) lesions. In 143 (34.8%) patients, FOB findings were normal. Out of 407 patients, FOB was suggestive of necrotic/nodular growth in 159 patients (39.1%), infiltrative growth in 8 patients (1.9%), and extrinsic compression was found in 39 patients (9.6%). In 143 patients (35.2%) no endobronchial growth was seen. Bronchial biopsy (BB) was performed in 162 (37.8%) patients, transbronchial lung biopsy in 56 patients (13.1%), bronchial washing for cytology in 350 patients (81.5%), bronchial washing for AFB in 302 patients (70.3%), bronchial washing for culture in 67 patients (15.6%), bronchial washing for fungus in 64 patients (14.9%) and Pneumocystis carinii infection was looked for in 6 patients (1.4%). Postbronchoscopy complications were recorded as follows: Early termination of FOB due to decreased O2 saturation in 10 cases (2.4%), postbiopsy bleeding in 5 cases (1.2%), post FOB fever in 5 cases (1.2%), chest pain in 7 patients (1.7%) and pneumothorax occurred in 2 patients (0.5%). FOB performed in outpatient setting is a useful and safe modality. Most patients in whom FOB was done in the present setup had suspected lung cancer. No major complications were encountered.     

Clinical profile of epilepsy, in a tertiary care centre of North-west India

The present study has been undertaken in a tertiary care centre of North-west India to know the clinical profile of epilepsy and response to drug therapy with special reference to study the effect of reduction of dosage of anti-epileptic drug after a seizure-free interval of two years. A total of 904 patients were selected during the period January, 2001 to October, 2006 who attended OPD clinic of the department of neurology, SMS Medical College and Hospital, Jaipur. Datailed clinical history was taken, general physical examination, routine blood examination, ECG and CT scan along with MRI (brain) in some cases were carried out. Of all the cases, sex ratio (male : female) was 2:1. A high proportion of cases (62.83%) were from low socio-economic group, 41.15% had normal EEG, 532 patients had normal CT scan (out of 800 cases). Single drug therapy was instituted in 71.67% cases. Patients went follow-up for 3 years. Most of the cases proved to be seizure-free after 2 years. Average maintenance dosage in patients on monotherapy can be reduced after a seizure-free interval of 2 years.     

Emergence of multidrug resistant enterococci at a tertiary care centre

Background

Enterococci have assumed great clinical importance because of their increasing resistance to various antimicrobial agents. Thus, knowledge about the antibiogram of these multidrug resistant isolates is of utmost importance in formulating an effective antibiotic policy to treat these infections and reducing the morbidity and mortality. Aim of this study was to assess the antimicrobial resistance pattern of enterococci and determine the prevalence of multidrug resistance among them.

Methods

This cross sectional study was carried out from August 2011 to February 2014, in which 200 non-repetitive clinical isolates of enterococci were included. Antimicrobial susceptibility testing was done by disc diffusion method. Minimum inhibitory concentration (MIC) of gentamicin, streptomycin, vancomycin, teicoplanin and linezolid was determined by E-test method.

Results

The prevalence of multidrug resistance among enterococcal isolates was found to be 63%. Varying levels of resistance was seen to various antibiotics. Most of the isolates were resistant to penicillin (95%), ampicillin (95%) and cotrimoxazole (90%). High level aminoglycoside resistance (HLAR) and glycopeptide resistance was seen in 39% and 14% isolates respectively. Only 4 isolates (2%) were found to be resistant to linezolid.

Conclusion

The prevalence of multidrug resistance among enterococci was found to be 63%, the resistance being more common in Enterococcus faecium as compared to Enterococcus faecalis. The study highlights the emergence and increased prevalence of multidrug resistant enterococci which pose a serious therapeutic challenge.     

Salivary gland lesions: a Jamaican perspective

A retrospective analysis of the spectrum and relative frequency of salivary gland lesions diagnosed in the Department of Pathology, University of the West Indies, Kingston, Jamaica, between 1965 and 1994, is reported. Four hundred and sixty-four salivary gland biopsies were received. Of these 99 (21.3%) were non-neoplastic and the remaining 365 (78.7%) were neoplasms: 261 (71.5%) were benign and 104 (28.5%) malignant. Benign mixed tumour (BMT)/pleomorphic adenoma (PA) was the most common neoplasm (63.3%) while mucoepidermoid carcinoma (MEC) was the most common malignant neoplasm (9.6%), followed by adenoid cystic carcinoma (ACC) (7.4%). The increased frequency of MEC over ACC is at variance with other reported series but the preponderance of pleomorphic adenoma is consistent. In the major salivary glands, benign neoplasms predominate at a ratio of 3:1, while a higher proportion of minor salivary gland neoplasms was malignant, ratio 1.2:1 (p = 0.003). These data represent the first attempt to document the spectrum of disease related to oral and maxillofacial pathology in Jamaica.     

Cadaveric renal transplantation: Our experience at a tertiary care centre in India

BackgroundRenal transplantation in developing countries like India is largely live donor transplantation. Cadaveric transplantation comprises <2% of all transplants in India.MethodsNinety-two cadaveric renal transplantations were included. Various donor and recipient characteristics were analysed along with graft and patient survival, using Kaplan–Meier method.ResultsThe mean age of the recipients was 35.5 ± 10.9 years while that of cadaver was 43.9 ± 17.0 years. Proportion of females among recipients was 47.8% while that of donors was 34.8%. The most common underlying pathology was chronic glomerulonephritis (44.6%). Antithymocyte globulin was used as induction in 84.8% of cases. Tacrolimus-based triple-drug regimen was most commonly used as maintenance (80.4%). The mean follow-up time was 39.02 ± 28.24 months. The most common cause of death was sepsis (47%). More than 50% deaths (9/17) occurred within first 3 years, while 61.5% of graft loss occurred 5 years after transplantation. The mean graft survival time was 81.6 months (95% confidence interval [CI]: 72.8–90.4). Cumulative proportion of graft survival was 91.6% at 3 years and 77.1% at 5 years. Although females have better mean graft survival time (91.6 vs 73.5 months), it was not a significant difference as shown by log-rank test (p value = 0.062). Pretransplant haemodialysis has no significant effect on graft loss, but patients on peritoneal dialysis have significantly higher odds of graft loss (odds: 4.86, p value < 0.05 [0.018]). The mean patient survival time was 99.5 months (95% CI: 84.0–114.9). Cumulative proportion of patient survival was 83.3% at 3 years and 70.8% at 5 years.ConclusionGraft and patient survival rate of cadaveric transplant at our centre was satisfactory. There is need to sensitise and augment the rate of cadaveric transplantation to increase the donor pool.     

Cutaneous leishmaniasis: a report of two cases seen at a tertiary dermatological centre in Singapore

Cutaneous leishmaniasis (CL) is not common in South-East Asia and often presents as a granulomatous plaque on the exposed areas, with a high index of suspicion required for diagnosis. Two such cases were seen at the National Skin Centre recently, and both were Gurkha men with a history of travel to Belize. They were treated with intravenous sodium stibogluconate with success. A discussion on CL and its management follows.     

Evolving changes in the management of early oesophageal adenocarcinoma in a tertiary centre

Objectives

Series from high volume oesophageal centres highlight an increasing prevalence of early malignant (EM) lesions. The advent of endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) offer alternatives to traditional surgery. The evolution of this pattern of care in a high volume centre is analysed.

Methods

Data were collected from a prospectively maintained database. 96 patients were treated with an EM lesion from 2000 to 2011. Surgery was the standard approach during the initial period (2000–2006). In 2007, with the introduction of EMR ± RFA to our Centre, a rising trend toward definitive endoscopic treatment was seen. This study details the selection of cases into treatment groups and their outcomes.

Results

From 2000 to 2006, 23 patients were treated with EM lesions, 96 % by surgery. Seventy-three were treated from 2007 to 2011, 55 % surgically and 45 % by EMR ± RFA. In the entire experience, there was one death from surgery and morbidity was higher in the surgery group compared with EMR ± RFA (p < 0.001). Three surgical patients (4.8 %) relapsed with HGD or cancer, and one patient with T1N1 disease died of disease recurrence. At a median of 13 months, EMR ± RFA offered 100 % disease control, 72 % had no endoscopic or histological evidence of Barrett’s oesophagus and one patient represented with low grade dysplasia.

Conclusions

This study highlights the changing pattern of care in the management of early oesophageal cancer. EMR ± RFA appears an acceptable alternative to surgery in carefully selected cases. However, long-term outcome analysis using these methods is required and close interdisciplinary collaboration of specialists in gastroenterology, surgery, pathology and radiology is mandatory to achieve optimum outcomes.     

Species distribution and antimicrobial resistance pattern of Coagulase-negative Staphylococci at a tertiary care centre

Background

Coagulase-negative Staphylococci (CoNS), previously dismissed at contaminants, have now emerged as an important cause of nosocomial infections especially in patients with implants and prosthetic devices. They are a well-known cause of bloodstream infections, urinary tract infections, wound infections, prosthetic valve endocarditis and eye infections. This study was conducted with an aim to identify CoNS at the species level from various clinical samples and determine the antimicrobial resistance pattern of these isolates.

Methods

This cross sectional study was carried out from September 2011 to February 2014 in which 150 non-repetitive clinical isolates of CoNS were identified at the species level by conventional phenotypic methods. Complete antimicrobial susceptibility profile was also determined by Kirby Bauer disc diffusion method. Susceptibility testing to vancomycin was done by E-test method.

Results

Only three species of CoNS were isolated, the most common being Staphylococcusepidermidis (60%) followed by Staphylococcussaprophyticus (27.3%) and Staphylococcushemolyticus (12.7%). Most S. epidermidis were isolated from blood and intravascular catheter tip samples, whereas all S. saprophyticus were isolated from urine samples of female patients. All isolates were found to be resistant to penicillin, but were susceptible to glycopeptides and linezolid and showed variable resistance to fluoroquinolones, aminoglycosides and macrolides.

Conclusion

CoNS are emerging nosocomial pathogens and should not always be overlooked as contaminants. However, growth of CoNS from blood cultures and intravascular catheter tips should be clinically correlated and carefully interpreted. As many CoNS strains exhibit drug resistance, antimicrobial susceptibility profile should be determined prior to treatment of these infections.     

Clinical profile of special children at asha centre

Background: The care of special children suffering from cerebral palsy, deaf mutism, mental retardation (MR) and post encephalitic sequelae etc. is done in the armed forces at “ASHA” centre supported by Army Wives Welfare Association (AWWA).